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The first sacral nerve root block (S1 NRB) is used to diagnose and treat lumbosacral and radicular pain. This study aims to clarify the anatomy of the S1 neural foramen using three-dimensional (3D) computed tomography (CT) images and to establish the optimal fluoroscopic angle, localize the S1 neural foramen on fluoroscopy, and determine the safe puncture depth for S1 NRB. In this single-center cohort study, 200 patients with lumbar degenerative disease who underwent preoperative CT were enrolled. Four distinct studies were conducted using the CT data. Study 1 examined the correlation of the sacral slope angle and the supine and prone positions. Study 2 analyzed the tunnel view angle (TVA) using 3D reconstruction. Study 3 ascertained the location of the S1 neural foramen in fluoroscopy images. Study 4 investigated the safe depth for performing S1 NRB. The regression analysis in Study 1 revealed a correlation of the sacral slope angle and the supine and prone positions. Study 2 determined an optimal fluoroscopic TVA of approximately 30° for the S1 NRB. Study 3 found that the S1 neural foramen was located caudal to the L5 pedicle 1.7 ± 0.2 times the distance between the L4 and L5 pedicles. Study 4 revealed that the depths of the S1 neural foramen and root were 27.0 ± 2.1 mm and 16.5 ± 2.0 mm, respectively. Our study suggests an optimal fluoroscopic angle, a simple method to locate the S1 neural foramen on fluoroscopy, and an ideal puncture depth for a safe and effective S1 NRB. [ABSTRACT FROM AUTHOR]

Access to high-quality MR exams is severely limited for patients with some implanted devices due to labeled MR safety conditions, but small-bore systems can overcome this limitation. For example, a compact 3 T MR scanner (C3T) with high-performance gradients can acquire exams of the head, extremities, and infants. Because of its reduced bore size and the patient being advanced only partially into the bore, the associated electromagnetic (EM) fields drop off rapidly caudal to the head, compared to whole-body systems. Therefore, some patients with MR conditional implanted devices can safely receive 3 T brain exams on the C3T using its strong gradients and a multiple-channel receive coil, while a corresponding exam on whole-body MR is precluded. The purpose of this study is to evaluate the performance of a small-bore scanner for subjects with MR conditional spinal or sacral nerve stimulators, or abandoned cardiac implantable electronic device (CIED) leads. The spatial dependence of specific absorption rate (SAR) on the C3T was compared to whole-body scanners. A device assessment tool was developed and applied to evaluate MR safety individually on the C3T for 12 subjects with implanted devices or abandoned CIED leads. Once MR safety was established, the subjects received a C3T brain exam along with their clinical, 1.5 T exam. The resulting images were graded by three board-certified neuroradiologists. The C3T exams were well-tolerated with no adverse events, and significantly outperformed the whole-body 1.5 T exams in terms of overall image quality. • Small-bore systems offer significant advantages for subjects with devices. • A compact 3T system has reduced head and body SAR compared to whole body 3T. • Devices limited to 1.5T can be safely scanned on compact 3 T with improved IQ. [ABSTRACT FROM AUTHOR]

To observe the therapeutic effect of bladder function training combined with repetitive sacral root magnetic stimulation (rSMS) on neurogenic bladder in patients with spinal cord injury. From January 2019 to May 2021, we selected 68 patients with neurogenic bladder and spinal cord injury who were hospitalized in the rehabilitation department of our hospital. Patients were divided into the rSMS group (36 cases) and control group (32 cases) according to a random number table. The rSMS group was treated with bladder functional training combined with rSMS, while the control group was treated only with bladder functional training. The training lasted for 40 days. Finally, we compared the therapeutic effects in the 2 groups. There was no significant difference in sex, age, course of disease, site, and grade of spinal cord injury between the 2 groups. There was no statistically significant difference in urodynamics between the 2 groups before treatment. After treatment, the residual urine volume of the rSMS group was 82.7 ± 34.6 mL, maximum urine flow rate was 15.7 ± 4.8 mL/second, bladder volume was 388.6 ± 51.3 mL, and bladder pressure was 36.3 ± 6.3 cm H 2 O. After treatment, the residual urine volume in the rSMS group was significantly less than that in the control group (P < 0.05). The maximum urine flow, bladder volume, and bladder pressure in the rSMS group were higher than those in the control group, and the differences were statistically significant (P < 0.05). After treatment and after 40 days of follow-up, the Barthel index scores of the patients in the rSMS group were 69.5 ± 9.3 and 73.5 ± 8.2, respectively, which were significantly higher than those of the patients in the control group (P < 0.05). The effective rates were 94.4% in the rSMS group and 81.3% in the control group, and the difference was statistically significant (P < 0.05). Compared with bladder function training alone, bladder function training combined with rSMS was more effective in the treatment of neurogenic bladder, particularly for detrusor hyporeflexia/areflexia; it significantly improved patients' ability to urinate autonomously, reduced the residual urine volume of the bladder, and improved patients' quality of life. [ABSTRACT FROM AUTHOR]

Overactive bladder is a manageable condition, with first-line treatment options including antimuscarinics, beta-3 agonists, and posterior tibial nerve stimulation. Second-line options include onabotulinumtoxin-A bladder injections or sacral nerve stimulation. The choice of therapies should be guided by individual patient factors. Overactive bladder syndrome (OAB) is highly prevalent among women and has a negative impact on their quality of life. The current available treatments for OAB symptoms include conservative, pharmacological, or surgical modalities. To provide an updated contemporary evidence document regarding OAB treatment options and determine the short-term effectiveness, safety, and potential harms of the available treatment modalities for women with OAB syndrome. The Medline, Embase, and Cochrane controlled trial databases and clinicaltrial.gov were searched for all relevant publications up to May 2022. The risk of bias assessment followed the recommended tool in the Cochrane Handbook for Systematic Reviews of Interventions , and quality of evidence was assessed using the modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. A meta-analysis was performed where appropriate. Antimuscarinics and beta-3 agonists were significantly more effective than placebo across most outcomes, with beta-3 agonists being more effective at reducing nocturia episodes and antimuscarinics causing significantly higher adverse events. Onabotulinumtoxin-A (Onabot-A) was more effective than placebo across most outcomes, but with significantly higher rates of acute urinary retention/clean intermittent self-catheterisation (six to eight times) and urinary tract infections (UTIs; two to three times). Onabot-A was also significantly better than antimuscarinics in the cure of urgency urinary incontinence (UUI) but not in the reduction of mean UUI episodes. Success rates of sacral nerve stimulation (SNS) were significantly higher than those of antimuscarinics (61% vs 42%, p = 0.02), with similar rates of adverse events. SNS and Onabot-A were not significantly different in efficacy outcomes. Satisfaction rates were higher with Onabot-A, but with a higher rate of recurrent UTIs (24% vs 10%). SNS was associated with 9% removal rate and 3% revision rate. Overactive bladder is a manageable condition, with first-line treatment options including antimuscarinics, beta-3 agonists, and posterior tibial nerve stimulation. Second-line options include Onabot-A bladder injections or SNS. The choice of therapies should be guided by individual patient factors. Overactive bladder is a manageable condition. All patients should be informed and advised on conservative treatment measures in the first instance. The first-line treatment options for its management include antimuscarinics or beta-3 agonists medication, and posterior tibial nerve stimulation procedures. The second-line options include onabotulinumtoxin-A bladder injections or sacral nerve stimulation procedure. The therapy should be chosen based on individual patient factors. [ABSTRACT FROM AUTHOR]

• Starr frame-assisted minimally invasive internal fixation stabilizes the anterior and posterior pelvic rings simultaneously. • Reduced waiting time from injury to surgery and intraoperative blood loss were observed in the perioperative period. • Postoperative weight-bearing and improved functional outcomes were observed. We aimed to investigate the surgical techniques, efficacy, and safety of Starr frame-assisted minimally invasive internal fixation for simultaneous anterior and posterior ring stability in pelvic fractures. The clinical data of 22 patients with anterior and posterior pelvic ring injuries who underwent Starr frame-assisted minimally invasive internal fixation were retrospectively collected. The anterior pelvic ring was fixed with an anterior subcutaneous internal fixator (INFIX), and the posterior pelvic ring was fixed with sacroiliac screws. The operative time, intraoperative blood loss, fluoroscopy times, number of assistants, complications, and weight-bearing time were analyzed. The Matta score was used to evaluate the fracture reduction. The Majeed score was used to evaluate clinical efficacy, and Gibbon's classification was used to estimate the occurrence of sacral nerve injury. All 22 patients were treated with sacroiliac screws for posterior ring injuries, including 12 cases with single sacroiliac screws, nine with two sacroiliac screws, and one with three sacroiliac screws. INFIX was used for all anterior ring fixation, including two screws in seven cases, three screws in 13 cases, and four screws in two cases. The fracture reduction quality was excellent in 15 cases, good in four cases, and moderate in three cases by Matta scores. All patients were followed up for 6–20 (12.5 ± 5.7) months. Callus-formation time based on postoperative X-ray was 3–8 (4.3 ± 1.2) weeks. Weight-bearing time was 3–12 (6.3 ± 2.8) weeks after surgery. At the last follow-up, 15 patients were evaluated as excellent, five as good, and two as fair according to the Majeed score. Gibbons' classification showed that one of the three patients with sacral nerve injury recovered completely and two did not recover. Complications occurred in six patients, including one with internal fixation loosening, two with anterolateral thigh paresthesia, one with malunion, one with nonunion, and one with heterotopic ossification. Starr frame-assisted minimally invasive internal fixation could stabilize the anterior and posterior pelvic rings simultaneously, overcoming the difficulty of fracture reduction. This technique can help patients with early postoperative weight-bearing and improved functional outcomes, providing a novel modality for the minimally invasive treatment of pelvic ring injuries. [ABSTRACT FROM AUTHOR]

Background Context: Lumbosacral fixation is commonly used for the management of lumbosacral instability. As the sacrum mainly consists of cancellous bone, bicortical fixation, in which the pedicle screw penetrates the anterior sacral cortex, can help increase the strength of fixation. However, this method carries a risk to the L5 nerves which lie anterior to the sacrum at this level.Purpose: The goal of this study is to determine a safe zone for the placement of S1 pedicle screws to decrease the likelihood of L5 nerve injury.Study Design: Retrospective imaging review.Patient Sample: This study evaluated imaging data of patients who underwent lumbar spine magnetic resonance imaging (MRI) at our institute between September 1, 2020 and September 1, 2021.Outcome Measures: T1-weighted axial MRIs were measured at the level of S1 pedicle screw placement. The space medial and lateral to the L5 nerve root on the anterior sacrum were measured and defined as safe zones. Additionally, the nerve width and sacral lengths were measured at this level.Methods: The distribution of the measurements were evaluated to determine a medial and lateral safe zone, as well as the average nerve width at the level of S1 pedicle screw placement. Correlation analysis was performed to determine a relationship between safe zone sizes and sacral size.Results: A total of 400 MRIs were analyzed. The average medial safe zone measured was 32.8 mm (95% CI: 32.2-33.4) with no nerves lying within 22.3 mm of the midline sacrum. The average lateral safe zone measured was 17.7 mm (95% CI: 17.1-18.2), with no nerves within 5.3 mm of the lateral border of the sacrum. The average nerve root width was 6.2 mm (95% CI: 6.13-6.34). An increased sacral length was associated with a larger medial (p<.001) and lateral (p<.001) safe zone.Conclusions: Our study revealed lateral and medial safe zones for the placement of S1 pedicle screws to avoid iatrogenic nerve injury in a retrospective cohort of 400 patients. There were no L5 nerve roots found within 22.3 mm of the sacrum's mid-axis or within 5.3 mm of the sacrum's anterolateral border. These defined safe zones can be used during pedicle screw planning and placement to decrease the risk of injury to the L5 nerve root. [ABSTRACT FROM AUTHOR]

The use of health-related quality-of-life scales has expanded into most areas of medicine. Established quality-of-life scales are used in several areas of neurosurgery, but none have been validated for use in patients with symptomatic Tarlov cysts. The majority of symptomatic Tarlov cysts are found in the sacral spinal canal of women. We, therefore, validated a site-specific quality-of-life measure for women with symptomatic sacral nerve root compression caused by Tarlov cysts. Women undergoing surgical treatment for sacral Tarlov cysts at a single institution between 2017 and 2020 were enrolled in this prospective validation study. Participants were administered a 13-item version of the survey along with other validated quality-of-life measures preoperatively and at 3 months postoperatively. Psychometric analyses were performed to validate the measure. One hundred twelve patients met inclusion criteria and completed surveys preoperatively and at 3 months postoperatively. Patients' mean scale scores decreased significantly preoperatively to postoperatively, reflecting good discriminability (P < 0.001). Interitem correlations suggested 2 items were correlated at >0.80, which were dropped to create an 11-item scale. The internal consistency of the 11-item scale was 0.822. Concurrent validity was established by correlating scale scores with the Oswestry Disability Index (P < 0.001) and the physical function (P < 0.001) and pain (P < 0.001) subscales of the Short-Form 36 Survey. We prospectively validated a site-specific, health-related quality-of-life survey for women with symptomatic sacral Tarlov cysts. This measure will be useful in future studies to inform clinicians and researchers about the progression of Tarlov cysts and patient response to surgical treatment. [ABSTRACT FROM AUTHOR]

This study aimed to determine the effects of sacral nerve electrical stimulation (SNS) on neuronal nitric oxide synthase (nNOS) in the colon and sacral cord of rats with defecation disorder after spinal cord injury (SCI). Rats with severe SCI (T10) were used as models and randomly divided into an SCI group and an SNS group. After 14 days of treatment, the intestinal transport function was assessed. Finally, the differences in nNOS immunoreactive cells, protein levels, nNOS mRNA, and NO content in the colon and sacral cord tissues were estimated using immunohistochemistry, Western blot, real-time polymerase chain reaction, and nitrate reductase method. The intestinal transport function of the SNS group was superior to that of the SCI group (P < 0.05). The average optical density of nNOS immunoreactive positive cells in the SCI group were significantly increased compared with those in the sham group. The content of NO of the SCI group significant increased compared with those of the sham group and the SNS group (both P < 0.01). The nNOS mRNA and protein expression was higher in the SCI group than in the sham group (P < 0.01), while that in the SNS group was significantly lower than that in the SCI group. SNS could reduce nNOS expression in the colon and sacral cord of SCI rats. This reduction may be an important neuromodulation mechanism for SNS to improve defecation reflex and promote the recovery of intestinal transit function. [ABSTRACT FROM AUTHOR]

Background: Sacral neuromodulation (SNM) is an advanced therapy that stimulates sacral spinal nerves to modulate bladder or bowel dysfunction and is approved for the treatment of overactive bladder, fecal incontinence, and non-obstructive urinary retention. Prior to implantation, a successful trial period must be performed via percutaneous nerve evaluation (PNE) or a staged trial to assess treatment efficacy. Ideal lead placement in the S3 foramen is imperative to produce an adequate response and successful outcome. Traditional lead placement with fluoroscopic guidance utilizes the anteroposterior (AP) and lateral views. In this abstract we describe an additional modification which may aid lead placement.Objective: This video demonstrates the bullseye technique to obtain S3 foramen access for optimal lead placement in SNM.Methods/material: Begin the procedure by placing the patient in the prone position. The medial edges of the S3 foramen are marked bilaterally in the AP view followed by a horizontal marking at the level of S3. The pelvis is imaged with live fluoroscopy starting at 0 degrees and then rotating the C-arm to 30 degrees. This rotation allows the "opening up" of the S3 foramen from an ellipsoid to an oval. The surgeon grasps the needle with a Kelly clamp, placing it at the level of the skin approximately 2 cm cephalad from the horizontal marking. Live fluoroscopy is performed to align the needle with the image intensifier to form the bullseye. Once the correct angle is identified, the needle is advanced. The procedure is repeated on the contralateral foramen.Results: The bullseye technique allows quick and predictable access into S3. It can potentially decrease operating time, minimize needle entries in PNE, and allows the surgeon to access S3 while maintaining proper medial orientation.Conclusion: The bullseye technique can assist surgeons in obtaining optimal access in SNM and can quickly be integrated into current practices. [ABSTRACT FROM AUTHOR]

Purpose: Craniospinal irradiation (CSI) is commonly used for pediatric brain tumors with a propensity for spread in craniospinal fluid, principally medulloblastoma. Evolving technology has led to the use of highly conformal radiation therapy (RT) techniques for CSI, including proton therapy. Target delineation and plan coverage are critical for CSI, but there is ongoing controversy and variability in these realms, with little available data on practice patterns. We sought to characterize proton CSI practice patterns in the United States by examining CSI plans in the Pediatric Proton/Photon Consortium Registry (PPCR).Materials and Methods: PPCR was queried for data on proton CSI patients from 2015 to early 2020. Each plan was manually reviewed, determining patient position; prescription dose; and coverage of optic nerves, vertebral bodies, spinal nerve roots, sacral nerves, and cranial foramina, among other variables. Two radiation oncologists blinded to clinical data and treating institution assessed coverage at the 95% prescription isodose line and per published European Society for Paediatric Oncology guidelines. Variability in coverage was assessed with nonparametric tests and univariate and multivariate logistic regression.Results: PPCR supplied data for 450 patients, 384 of whom had an evaluable portion of a CSI plan. Most patients (90.3%) were supine. Optic nerves were fully covered in 48.2%; sacral nerves in 87.7%; cranial foramina in 69.3%; and spinal nerves in 95.6%. Vertebral body (VB) sparing was used in 18.6% of skeletally immature cases, increasing over time (P < .001). Coverage in all categories was significantly different among treating institutions, on univariate and multivariate analyses. Cribriform plate deficits were rare, with marginal misses of the foramen ovale (17.4%) and frontal lobe (12%) most common.Conclusion: We found consistent variation based on treating institution in proton CSI practices including optic nerve, VB, sacral nerve, cranial, and spinal nerve coverage. These data may serve as a baseline quantification of current proton CSI practices in the United States as they continue to evolve. [ABSTRACT FROM AUTHOR]

To develop an ultrasound-guided interfascial plane technique for injection of the pudendal nerve near its sacral origin in cats. Prospective, randomized, anatomical study. A group of 12 feline cadavers. Gross and ultrasound anatomy of the ischiorectal fossa, the pudendal nerve relationship with parasacral structures, and the interfascial plane were described. Computed tomography was employed to describe a cranial transgluteal approach to the pudendal nerve. Bilateral ultrasound-guided injections were performed in eight cadavers using low [(LV) 0.1 mL kg–1] or high volume [(HV) 0.2 mL kg–1] of ropivacaine–dye solution. Dissections were performed to determine successful staining of the pudendal nerve (>1 cm) and inadvertent staining of the sciatic nerve, and any rectal, urethral, or intravascular puncture. Pudendal nerve staining in groups LV and HV were compared using Fisher's exact and Wilcoxon rank-sum test as appropriate (p = 0.05). The pudendal nerve and its rectal perineal and sensory branches coursed through the ischiorectal fossa, dorsomedial to the ischiatic spine. The pudendal nerve was not identified ultrasonographically, but the target plane was identified between the sacral transverse process, the ischiatic spine, the pelvic fascia and the rectum, and it was filled with dye solution. Both branches of the pudendal nerve were completely stained 75% and 87.5% in groups LV and HV, respectively (p = 1.00). The dorsal aspect of the sciatic nerve was partially stained in 37% of injections in group HV. Rectal or urethral puncture and intravascular injection were not observed. In cats, ultrasound-guided cranial transgluteal injection successfully stained the pudendal nerve in at least 75% of attempts, regardless of injectate volume. Group HV had a greater probability of sciatic nerve staining. [ABSTRACT FROM AUTHOR]

Context: Rectal cancer is common and it is often treated by surgery with or without chemoradiation. Cancer treatment frequently results in bowel symptoms.Objectives: The review aim was to chart the management options for bowel symptoms following rectal cancer surgery.Methods: A scoping review was undertaken searching nine healthcare databases, using relevant search terms and Boolean operators following PRISMA-ScR guidance. Data were extracted into an Excel spreadsheet using headings from the United Kingdom Department of Health guidance and are reported narratively.Results: 30 heterogeneous studies met the inclusion criteria, including 853 patients. The most commonly reported bowel symptom was fecal incontinence; the most frequent management strategy was sacral nerve stimulation. Most studies reported on a single management option, often used to manage more than one bowel symptom. Often failure to satisfactorily improve symptoms using options such as medication was needed prior to progressing to other management options. In some studies more than one management option was used, such as rehabilitation programmes.Conclusion: It is likely that to effectively manage the bowel symptoms experienced after rectal cancer treatment, more than one management option may be used-. Additionally, different management options may need to be tried concurrently. [ABSTRACT FROM AUTHOR]

Introduction: Urinary urgency is a very strong urge to urinate that is difficult to postpone and control. One of the physiotherapeutic resources that can be used in the treatment of urinary urgency is electrical nerve stimulation. The objective of this study is to investigate the effects of parasacral and tibial nerve transcutaneous electrical stimulation in improving urinary urgency in adult women.Material and Methods: Single-blinded randomized controlled clinical trial.Participants: Ninety-nine adult women with urgency.Interventions: Transcutaneous electrostimulation for 12, 20-min sessions, twice a week. The tibial and parasacral groups received a current of F = 10 Hz and 200 μs pulse duration, while the sham group received a current of F = 100 Hz and 100 μs pulse duration, the active electrode placed over the scapula. Primary and secondary outcome measures: The primary outcome measure was urinary urgency, measured by the International Consultation on Incontinence Questionnaire Overactive Bladder (ICIQ-OAB) and Overactive Bladder questionnaire-Validated 8-Question Awareness Tool (OAB-V8). Secondary outcomes were quality of life with the King's Health Questionnaire (KHQ) and voiding habits with the 24-h voiding diary. Assessments occurred pretreatment, after the sixth and 12th post-treatment sessions and at the 30-day follow-up.Results: Both parasacral and tibial groups in the post-treatment presented fewer episodes of urgency than the sham group. The parasacral group showed better results than the sham group post-treatment for ICIQ-OAB scores, and in KHQ domains Impact of Incontinence and task limitations. Parasacral group participants had OAB-V8 score lower than 8 in the post-treatment and follow-up.Conclusion: Both tibial and parasacral groups had a positive and similar effect on reducing urinary urgency in adult women. Relative to the quality of life, transcutaneous parasacral electrostimulation was superior to transcutaneous tibial electrostimulation.Clinical Trial Registration: Brazilian Registry of Clinical Trials (ReBEC), http://ensaiosclinicos.gov.br, protocol RBR-9rf33n. [ABSTRACT FROM AUTHOR]

• Neurogenic detrusor overactivity severely and negatively impacts an individual's quality of life. • Currently available treatments result in refractory cases and have a high risk of side effects. • Genital nerve stimulation (GNS) is proven to retard involuntary bladder contraction. • At-home GNS has a beneficial carry-over effect on incontinence after being stopped. Genital nerve stimulation (GNS) is a promising, but under-researched, alternative treatment for neurogenic detrusor overactivity (NDO) in those with spinal cord injury (SCI). To investigate the urodynamic, quality-of-life (QOL) and carry-over effects of GNS when applied at home for 2 weeks by participants with incomplete SCI and NDO during activities of daily living. Seven men and 1 woman participated in this 1-month protocol study. Urodynamic and QOL data were gathered during week 1 (baseline measurements), followed by 2 weeks of daily GNS at home using a portable device. GNS was applied either on-demand or thrice daily, depending on the individual's sensation. At week 4, post-stimulation tests were repeated to record any carry-over effect from the GNS. Participants maintained voiding diaries throughout the study. Assessments were carried out at the end of each protocol period in a randomized order. Clinical procedures were conducted at Taipei Medical University Hospital (Taipei, Taiwan). Everyone completed the study but only 7 of the 8 participants completed their voiding diary. Two weeks after GNS, average cystometric bladder capacity was increased by 30 % compared to baseline (P < 0.05). A 1-week carry-over effect was demonstrated as this capacity remained, on average, 35 % greater than baseline in week 4 after GNS was stopped (P < 0.05). Incontinence frequency significantly decreased by the end of week 3 (P < 0.05) but no significant improvements were recorded for either detrusor pressure or bladder compliance. Chronic at-home GNS improved cystometric bladder capacity and reduced urinary incontinence for individuals with incomplete SCI and NDO. A carry-over effect of 1 week was observed following GNS treatment. The use of portable GNS treatment that can be applied by the individual at home merits further investigation as alternative treatment for NDO in those with SCI. [ABSTRACT FROM AUTHOR]

Objective: To investigate the feasibility of erectile function restoration by the genitofemoral nerve to pelvic nerve transfer in rats.Methods: Thirty-six male rats were included in this study. Rats in the nerve transfer group (n = 12) were subjected to pelvic nerve, sacral roots, and L6 roots transection and then bilateral genitofemoral nerve to pelvic nerve transfer, rats in the nerve resection group (n = 12) were subjected to pelvic nerve, sacral roots, and L6 roots transection without nerve transfer, and rats in the control group (n = 12) served as controls. After reinnervation, intracavernous pressure (ICP) assessment was performed. Fluoro-Gold was injected into the corpus cavernosum. Immediately before euthanasia, transferred nerves were stimulated to test penile intracavernous pressure. The L6, S1, and L1-2 spinal cord segments were used for retrogradely labeled neurons. Regenerative nerve morphologic examination assessment was performed.Results: Genitofemoral nerve stimulation induced an increase in ICP in the nerve transfer group. The mean ICP in this group was (33.8 ± 9.4 mm Hg), which is higher than the mean value in the nerve resection group (3.9 ± 1.0 mm Hg) but lower than that in the control group (69.8 ± 12.2 mm Hg; P < .05). The formation of new neural pathways was confirmed by the appearance of Fluoro-Gold labeled neurons in the L-1 and L-2 spinal cord segments in the nerve transfer group. Regenerative nerve morphologic examination showed good axonal regeneration after genitofemoral nerve transfer.Conclusion: Nerve regeneration can be obtained by genitofemoral nerve to pelvic nerve transfer, and erectile function can be restored. [ABSTRACT FROM AUTHOR]

The field of electroceuticals has attracted considerable attention over the past few decades as a novel therapeutic modality. The gastrointestinal (GI) tract (GIT) holds significant potential as a target for electroceuticals as the intersection of neural, endocrine, and immune systems. We review recent developments in electrical stimulation of various portions of the GIT (including esophagus, stomach, and small and large intestine) and nerves projecting to the GIT and supportive organs. This has been tested with varying degrees of success for several dysmotility, inflammatory, hormonal, and neurologic disorders. We outline a vision for the future of GI electroceuticals, building on advances in mechanistic understanding of GI physiology coupled with novel ingestible technologies. The next wave of electroceutical therapies will be minimally invasive and more targeted than current approaches, making them an indispensable tool in the clinical armamentarium. Electrical stimulation of the gastrointestinal (GI) tract through implanted stimulators can modulate motility, hormone release, and neural signaling. Studies show that electrical stimulation of GI tissue and nerves can be an effective therapy for several conditions including gastroesophageal reflux disease, gastroparesis, inflammatory bowel disease, and fecal incontinence. Varying electrical stimulation parameters and placement can have a significant impact on treatment efficacy. Ingestible electrotherapies that target specific sections and tissues along the GI tract hold significant potential for the treatment of GI, immune, neurologic, and endocrine disorders. [ABSTRACT FROM AUTHOR]

Objective: To assess efficacy of combined pelvic floor interferential (IF) electrical stimulation and muscle exercises on bladder bowel dysfunction (BBD) in children.Materials and Methods: A total of 34 children with BBD (6 boys, 28 girls; mean age 7.4 ± 2.2) were included in this study. Children were evaluated with kidney and bladder ultrasounds, uroflowmetry + electromyography (EMG), and a complete voiding and bowel habit diary before treatment. Exclusion criteria were neuropathic disease, anatomical defects, and mental retardation. Participants were randomly allocated into 2 treatment groups including group A (n = 17) who underwent IF electrical stimulation in addition to pelvic floor muscle (PFM) exercises and group B (n = 17) who received PFM exercises alone. All children were re-evaluated by kidney and bladder ultrasounds, uroflowmetry + EMG and a voiding and bowel habit diary at the end of treatment sessions and 6 months later.Results: Constipation improved in 14 of 17(82%) and 8 of 17(47%) children in group A and B respectively at the end of treatment sessions (P = .03). Daytime incontinence improved in all children in group A and 2 of 8(25%) children in group B after the treatment (P = .007). Urinary tract infection improved in 8 of 10(80%) and 5 of 13(38.4%) children in group A and B respectively, 6 months after the treatment (P = .02). No significant difference was observed in uroflowmetry measures between 2 groups after the treatment.Conclusion: Combination of IF electrical stimulation and PFM exercises is an effective and safe modality for treatment of BBD in children. [ABSTRACT FROM AUTHOR]

Objective: To assess the efficacy, safety, and outcomes of sacral nerve stimulation (SNS) for Parkinson's disease (PD) patients with overactive bladder symptoms.Methods: We retrospectively reviewed PD patients who underwent Stage I SNS. Demographics, urodynamic data, and baseline voiding function were analyzed. Efficacy and safety of treatment were determined by rate of progression to Stage II, explantation, and surgical revision. Long-term outcomes were assessed using voiding diaries and/or clinic notes.Results: Sixty percent (9/15) experienced ≥50% improvement in urinary parameters and proceeded to Stage II. There was no significant difference in age, body mass index, comorbidities, PD disease duration, or levodopa equivalent daily dose between successful and nonsuccessful Stage I patients. However, 100% of female patients experienced Stage I success compared to 44% of male PD patients (P = .04). Individuals with >12-month follow-up experienced an average reduction of 6 voids/day. No patients required revision or explantation of their device at latest clinic follow-up (22.2 ± 7.8 months). Higher maximal urethral closure pressures, detrusor pressure at maximum flow rate (PdetQmax), post-void residual volume, and mean bladder outlet obstruction index were observed in the Stage I trial failures.Conclusion: At our institution, PD patients have a similar rate of progression to Stage II compared to the general population. SNS is an effective therapy that should be considered among the treatment options for PD patients with overactive bladder symptoms. Urodynamic parameters associated with obstruction may be predictive of SNS failure in PD patients and may help guide patient selection, however further studies are needed. [ABSTRACT FROM AUTHOR]

Background: Low-frequency oscillations (LFO) detected in the internal globus pallidus of dystonia patients have been identified as a physiomarker for adaptive Deep Brain Stimulation (aDBS), since LFO correlate with dystonic symptoms and are rapidly suppressed by continuous DBS (cDBS). However, it is as yet unclear how LFO should be incorporated as feedback for aDBS.Objectives: to test the acute effects of aDBS, using the amplitude of short-lived LFO-bursts to titrate stimulation, to explore the immediate effects of cDBS on LFO-modulation and dystonic symptoms, and to investigate whether a difference in the resting-state LFO is present between DBS-naïve patients and patients with chronic DBS.Methods: seven patients were assessed during either DBS-implantation (n = 2) or battery replacement surgery (n = 5), and pseudorandomized in three conditions: no stimulation, cDBS, and aDBS. Additionally, resting-state LFP-recordings from patients undergoing battery replacement were compared to those obtained during DBS-implantation; LFP-recordings from a previous cohort of six dystonia patients undergoing DBS-implantation were incorporated into this analysis (total n = 8 newly implanted patients).Results: we corroborated that a mild LFO-suppression rapidly occurs during cDBS. However, no acute changes in clinical symptoms were observed after cDBS or aDBS. Remarkably, we observed that resting-state LFO were significantly lower in patients who had been effectively treated with chronic cDBS compared to those of newly implanted patients, even when stimulation was suspended.Conclusions: our results indicate that LFO-suppression in dystonia, similar to symptom response to cDBS, might be gradual, and remain after stimulation is suspended. Therefore, tracking gradual changes in LFO may be required for aDBS implementation. [ABSTRACT FROM AUTHOR]

Objective: To determine if racial and/or socioeconomic factors influence advanced therapy utilization for refractory overactive bladder (OAB) among the commercially insured.Methods: We queried Optum, a national claims database, between 2003 and 2017. Non-neurogenic OAB patients were identified using ICD-9/10 diagnosis codes. Demographic and treatment data were collected, including oral medication therapies (anticholinergic, beta3 agonists), and advanced therapies (OnabotulinumtoxinA [BTX], Sacral Nerve Stimulation [SNS], percutaneous tibial nerve stimulation [PTNS]). Associations between patient sociodemographic factors and advanced therapy utilization were explored.Results: Of 4,229,617 OAB patients, 807,612 (19%) received medical therapies, of which 95% received oral medications only and only 4.7% received advanced therapies. Asians had the lowest use of oral therapy use (14% vs 18%-19% in other races/ethnicities, P <0.05), and advanced therapy use (0.44% vs 0.71%-0.93%, P <0.05). Asians and Hispanics were least likely to utilize SNS therapy and most likely to use PTNS compared to Blacks and Whites. BTX use was similar between races/ethnicities (P <0.05). Female gender (OR 1.65 [CI 1.61,1.69]), younger age (<65) (OR 1.28 [1.25,1.31]), higher annual income ≥$40K (OR 1.09 [1.06,1.12]) and prior use of oral medications (OR 3.30 [3.21,3.38] for 1 medication) were significantly associated with receiving advanced therapies. Non-white race (OR 0.89 [0.87,0.91]), lower education level (less than a bachelor's degree) (OR 0.97 [0.94,0.99]), and Northeast region were associated with a lower likelihood of receiving advanced therapies (P <0.05 for all).Conclusion: Among commercially insured, racial and socioeconomic factors predict utilization of advanced OAB therapies, including race/ethnicity, age, gender, education level, and region. [ABSTRACT FROM AUTHOR]

Objective: To provide an anatomical atlas made of serially sectioned images of a female cadaver that clearly demonstrated the pudendal nerve.Materials and Methods: The courses of the pudendal nerve, internal pudendal artery, and internal pudendal vein were observed on the sectioned images of a female cadaver. The spatial relationship between the nerve and blood vessels was interpreted.Results: Traces of the structures on the sectioned images showed that the sources of the sciatic and pudendal nerves were the fourth lumbar nerve to the second sacral nerve and the second to the fourth sacral nerves, respectively. As the borderline, the second sacral nerve showed a remarkable variation. The pudendal nerve gave off the internal rectal nerve proximal to the pudendal canal and it gave off the muscular branch to the urogenital triangle in the pudendal canal. It was divided into the posterior labial nerve and the dorsal nerve of clitoris distal to the pudendal canal. Inside the pudendal canal, the internal pudendal vein, internal pudendal artery, and pudendal nerve were arranged from superomedial to inferolateral order. In other words, the pudendal nerve was the farthest from the uterus.Conclusion: The sorted sectioned images with labels, accompanied by the schematic drawings, could serve as references for interpreting clinical images and conducting procedures related to pudendal nerve conditions. [ABSTRACT FROM AUTHOR]

Objective: To evaluate utilization of third-line overactive bladder (OAB) treatments including percutaneous tibial nerve stimulation (PTNS), sacral nerve stimulation (SNS), and intradetrusor botulinum toxin A (BTX) among privately insured patients and examine factors associated with their use.Materials and Methods: Using MarketScan claims (2015-2017), we identified patients who underwent third-line OAB treatments based on procedure codes. Factors of interest included location, age, health plan, among others. We fit multivariable logistic regression models to estimate associations between pertinent factors with receipt of PTNS and SNS relative to BTX and associations between provider type and practice location with each treatment modality.Results: We identified 7383 patients (mean age 50.9) in our cohort. SNS was used most frequently (n = 3602, 48.8%), while PTNS was used least frequently (n = 955, 12.9%). PTNS patients were more likely to reside in metropolitan areas (vs BTX: OR 1.6, 95%CI 1.3-2.1; vs SNS: OR 2.2, 95%CI 1.7-2.8), be aged 55 years or older (vs BTX: 54% vs 47%, OR 1.6, 95%CI 1.2-2.1; vs SNS: 54% vs 45%, OR 1.6, 95%CI 1.2-2.0), and be covered under a health maintenance organization (vs BTX: 17% vs 10%; vs SNS: 17% vs 10%, P <.01). Urologists were most likely to perform SNS, and gynecologists were most likely to perform BTX. 91% of PTNS procedures were performed in office settings.Conclusion: Among patients receiving third-line OAB treatment, PTNS was used infrequently. PTNS utilization was concentrated within urban areas, and among older patients and those covered by cost-conscious health maintenance organizations. [ABSTRACT FROM AUTHOR]

• Study shows important inter-individual variability in myotome innervation among patients. • Most muscles have multi-radicular innervation. • Root territories strongly overlap, not only under dorsal but also ventral stimulation at threshold. Most of knowledge on muscle radicular innervation was from explorations in root/spinal cord pathologies. Direct and individual access to each of the lumbar-sacral -ventral and dorsal- nerve roots during dorsal rhizotomy for spastic diplegia allows precise study of the corresponding muscle innervation. Authors report the lumbo-sacral segmental myotomal organization obtained from recordings of muscle responses to root stimulation in a 20-children prospective series. Seven key-muscles in each lower limb and anal sphincter were Electromyography (EMG)-recorded and clinically observed by physiotherapist during L2-to-S2 dorsal rhizotomy. Ventral roots (VR), for topographical mapping, and dorsal roots (DR), for segmental excitability testing, were stimulated, just above threshold for eliciting muscular response. In 70% of the muscles studied, VR innervation was pluri-radicular, from 2-to-4 roots, with 1 or 2 roots being dominant at each level. Overlapping was important. Muscle responses to DR stimulation were 1.75 times more extended compared to VR stimulation. Inter-individual variability was important. Accuracy of root identification and stimulation with the used method brings some more precise information to radicular functional anatomy. Those neurophysiological findings plead for performing Intra-Operative Neuromonitoring when dealing with surgery in the lumbar-sacral roots. [ABSTRACT FROM AUTHOR]

• The success rate of sacral nerve modulation for faecal incontinence after pelvic radiotherapy is high. • The revision rate are low in these patients. • These results support the recommendation to propose at least a sacral nerve modulation test to these patients. To assess the efficacy and safety of sacral nerve modulation (SNM) in patients with faecal incontinence (FI) after pelvic radiotherapy in comparison with results of SNM for FI related to other conditions. Prospectively collected data from patients who underwent SNM therapy between January 2010 and December 2015 at 7 tertiary colorectal units were reviewed retrospectively. Patients with FI following pelvic radiotherapy were identified and matched (1:2) for age and sex with 38 patients implanted over the same period for FI without previous radiotherapy. The treatment was considered favourable if the patient reported any therapeutic benefit from SNM, had no further complaints or interventions and did not consider stopping the treatment. Long-term results, surgical revision and definitive explantation rates were compared. Among 352 patients who received a permanent SNM implant, 19 (5.4%) had FI following pelvic radiotherapy. After a mean follow-up of 3.5 ± 1.9 years, the cumulative successful treatment rates were similar between the groups (p = 0.60). For patients with FI following pelvic radiotherapy, the cumulative success rates were 99.4% [85.4–99.8], 96.7% [78.1–99.6], 91.7% [70.4–98.1] and 74.6% [48.4–94.8] at 1, 2, 3 and 5 years respectively. The revision and definitive explantation rates for infection did not differ significantly. The long-term success rate of SNM for FI after pelvic radiotherapy is similar to that of SNM for FI related to other more frequent conditions. Our study suggests that FI after pelvic radiotherapy could be improved with SNM without an increased risk of complication. [ABSTRACT FROM AUTHOR]

En-bloc sacrectomy is the treatment of choice for patients affected by sacral chordoma. It is a radical surgical procedure, which has to face the problem of handling fragile anatomic structures, such as the internal iliac vessels and the sacral nerve roots, with the risk of causing bowel, bladder, and sexual dysfunction. The combined anterior-posterior approach allows for a safer dissection of the tumor from the mesorectal fascia than the mere posterior approach, especially for tumors extending proximally to S3. Robotic surgery can improve the safety of the procedure. Sacral nerve stimulation is an accepted therapeutic option for fecal incontinence and may be used to treat postoperative incontinence. We report on a patient affected by sacral chordoma with en-bloc sacrectomy preceded by a robotic-assisted dissection of the mesorectal fascia and on managing the postoperative fecal incontinence by implanting a sacral nerve stimulator on the first postoperative day. To our knowledge this is the first such procedure in the literature. From our experience, a robotic anterior approach increases safety for the organs in the pelvis when performing a sacrectomy. Moreover, a sacral nerve stimulator should be considered to manage neurologic complications following transection of nerve roots after sacrectomy. [ABSTRACT FROM AUTHOR]

Artificial anal sphincter is considered to be a good method for the treatment of severe fecal incontinence, but there are problems of low biomechanical compatibility in clinical application. The purpose of this study is to design a novel artificial anal sphincter that can output stable loading force to solve the mechanical mismatch between artificial anal sphincter and intestinal tissue caused by excessive or too small local pressure on the intestine. Aiming at the shortcomings of the existing artificial anal sphincter, a novel artificial anal sphincter with constant force mechanism is designed based on the C-shaped SMA sheet of Ti-55.9at%Ni and combined with the normal defecation mechanism of human body. In this paper, the chord length l of C-shaped SMA sheet is used as the design variable, and the artificial anal sphincter is optimized and verified initially by using finite element analysis method. The results show that the artificial anal sphincter can achieve a constant force to clamp the intestine in a large displacement range when the chord length l of the C-shaped SMA is 13 mm, the chord height h is 1.5 mm, the width w is 2 mm, and the thickness δ is 0.2 mm. The design of artificial anal sphincter with constant force loading mechanism has a good effect in solving the biomechanical compatibility problem between the implant device and the intestinal tissue. In addition, the designed artificial anal sphincter occupies a small space, which provides a new idea for future clinical application. • A novel artificial anal sphincter with radial contraction is designed. • A constant force loading mechanism is designed to output stable force. • Constant force performance of artificial sphincter is verified by FEA. [ABSTRACT FROM AUTHOR]

• Heterogenous mechanics and structure of the spine system, including intervertebral bodies and discs, were visualized by finite element analysis. • Heterogeneous architected lattice structure was achieved by a parametrical modeling strategy. • The well-designed heterogeneous structure triggered the stress reorganization on intervertebral cage mimicking the natural stress distribution. • The heterogeneous design promote spinal fusion compared to conventional design. The common phenomenon of cage subsidence after intervertebral fusion may lead to intervertebral foramen stenosis and implantation failure. In this study, a heterogeneous porous cage was designed to trigger the stress reorganization so as to avoid intervertebral cage subsidence and promote spinal fusion. Firstly, finite element analysis (FEA) was used to predict the heterogenous stress distribution on intervertebral discs. Then, a heterogeneous porous structure cage was inspired by the stress reorganization method. Parametrical modeling was employed to customize the porous structure of the cage. Heterogenous Ti6Al4V cage was successfully fabricated via selective laser melting 3D printing. The results from FEA simulation indicated that heterogenous cage with a dense periphery and a porous center may drive the load outward which mimicking the natural stress distribution of spine system. Finally, an animal model between the C3-C4 vertebras of goats was studied to prove the effectiveness of the cage fusion. The histological and micro-CT results indicated that the heterogeneous structure may accelerate bone tissue ingrowth so as to promote osteointegration and fusion. Compared with conventional cage, the heterogenous cage may avoid subsidence and this heterogenous structure provide a promising strategy for customized bio-fusion intervertebral cage. [ABSTRACT FROM AUTHOR]

Sacral schwannomas are very rare nerve sheath tumors. Patients usually present with a variety of nonspecific symptoms, which often lead to a delay in diagnosis. Although most schwannomas are benign, they present surgical challenges owing to their proximity to neurologic and other anatomic structures. This 58-year-old female presented with a 2-month old history of left-sided perineal and radicular pain secondary to a right S2 sacral nerve root schwannoma. The sacral mass demonstrated homogenous enhancement with cystic changes in a T2-weighted magnetic resonance imaging sequence. The patient underwent S1–S3 laminectomy and tumor excision through a posterior surgical approach. Intraoperative monitoring was used to distinguish nonfunctional tissue during tumor resection. The patient had an unremarkable postoperative course. Sacral schwannomas can present with a variety of nonspecific symptoms. They pose unique challenges given their location, size, and involvement of surrounding structures. Complete surgical resection is the main goal of sacral schwannoma treatment. A combined anterior-posterior surgical approach and a multidisciplinary surgical team are associated with improved outcomes. [ABSTRACT FROM AUTHOR]

Objectives: To determine patient factors prompting anterior abdominal wall placement of the sacral nerve stimulator implantable pulse generator and investigate revision and infection rates for buttock (standard) and abdominal placement.Methods: We retrospectively reviewed records of consecutive sacral nerve stimulation procedures by a single surgeon from 2012 to 2017 at a single institution.Results: 75 patients underwent sacral nerve stimulation--60 with standard and 15 with abdominally placed implantable pulse generators. The mean age and body mass index of the standard group was higher than that of the abdominal group and the majority was female. A greater proportion of patients in the abdominal group had a neurological diagnosis and was wheelchair-dependent. Overall, a total of 20 patients underwent 38 revision surgeries. The indications for revision surgery were pain, loss of efficacy, or lead migration. The standard group accounted for more revisions than the abdominal group (34vs 4 cases, P = .048), with no revisions due to pain in the abdominal group. The infection rate (2% vs 13%, P = .10), average time from implantation to revision, and operative duration were not statistically different between groups.Conclusion: In a subset of patients who were wheelchair-dependent or lacked gluteal fat, placement of the implantable pulse generator in the anterior abdominal wall resulted in no revisions due to pain. Operative duration and infection rates were similar between abdominal and standard placement. Abdominal placement with extended length leads could be considered as a primary or revision option in these select patients. [ABSTRACT FROM AUTHOR]

Objective: Fracture line of the sacrum always involves the Zone II region because sacral foramina are anatomically and physiologically weak regions of the sacrum. The purpose of this study is to compare the therapeutic effects of a sacroiliac screw and a minimally invasive adjustable plate (MIAP) for Zone II sacral fractures.Methods: Patients with unilateral Zone II sacral fractures fixed with a unilateral sacroiliac screw or MIAP from August 2009 to January 2016 were recruited into this study and were divided into two groups: group A (sacroiliac screw) and group B (MIAP). Surgical time, blood loss, frequency of intraoperative fluoroscopy, and relative complications were reviewed. Radiographs and CT scans were routinely acquired to evaluate the fracture displacement and reduction quality. Fracture healing was evaluated in the radiographs at each follow-up. Functional outcome was assessed based upon the Majeed scoring system at the final follow-up.Results: Thirty-one patients in group A and thirty-nine patients in group B were included in this study. No significant differences in average surgical time (P = 0.221) or blood loss (P = 0.234) were noted between group A and group B. The mean frequency of intraoperative fluoroscopy was 15.74±2.98 in group A and 6.08±1.94 in group B (P = 0.000). All fractures healed well within four months in all patients, and the healing time exhibited no significant difference between the two groups (P = 0.579). Satisfactory rates of reduction quality and functional outcome were not statistically different between the two groups (P > 0.05). The complication rate was 16.13% (5/31) in group A and 5.13% (2/39) in group B (P = 0.222).Conclusion: MIAP has a fixation effect and exhibits reduction potential for Zone II sacral fractures. Favourable radiographic and functional results could be obtained through the MIAP technique, which is easy to conduct without pre-contouring. Compared with the unilateral S1 sacroiliac screw technique, repeated projections and iatrogenic sacral injury can be avoided. [ABSTRACT FROM AUTHOR]

Background Spasticity and muscle weakness are common severe neurologic sequelae after stroke. Contralateral peripheral neurotization has been applied successfully to promote motor function of the hemiplegic upper extremity in patients with central neurological injury. To our knowledge, we present the first report of contralateral lumbar to sacral nerve transfer for the lower extremities in hemiplegic patients after stroke. Case Description Two patients were enrolled in the study. The first patient is a 57-year-old man who experienced permanent muscle weakness in his left leg after a right cerebral infarction. The second patient is a 42-year-old man who had spasticity and hemiplegia in both upper and lower limbs on the right side 32 months after a left cerebral hemorrhage. Both patients underwent contralateral lumbar–to–sacral nerve rerouting to improve lower-limb motor function. Twenty months after surgery, both patients experienced significant improvement in ambulatory status. Conclusions Although long-term follow-up and a randomized controlled trial are required, this study demonstrates the safety and possible benefits of contralateral lumbar–to–sacral nerve transfer for hemiplegic patients after stroke. This novel surgical approach could provide a new means for lower-limb motor functional recovery. Highlights • Spasticity and muscle weakness are common severe neurologic sequelae after stroke. • We report contralateral lumbar to sacral nerve transfer for the lower extremities in hemiplegic patients after stroke. • This new surgical technique could provide a new method for lower-limb motor functional recovery. [ABSTRACT FROM AUTHOR]

In children, erythromelalgia is a rare but difficult to manage condition that results in bilateral episodic pain and redness in distal extremities. It is heat intolerant and relieved by cooling. Management of erythromelalgia is difficult and requires a complex multidisciplinary approach. We present a case of successful treatment of erythromelalgia with short-term spinal cord stimulation in a 12-year-old girl. The patient had severe burning pain, having undergone trials of multiple medical therapies before presenting to our department. Dual-lead spinal cord stimulator electrodes were successfully implanted without complication, leading to excellent pain control, now 8 months postimplant. This case spurs interest for future research in neuromodulation as part of the multimodal regimen to treat pediatric erythromelalgia. [ABSTRACT FROM AUTHOR]

Introduction: Sacral nerve stimulation (SNS) is increasingly popular in the management of faecal incontinence. This paper reports the first 10-year experience of SNS in the management of faecal incontinence at a tertiary referral centre. Data was collected in a prospectively maintained database.Results: In total 130 patients were referred. The majority were women (94%) under 75-year-old (98%). Seven patients were found to have full-thickness rectal prolapse at the initial work-up and proceeded to rectopexy. Eighty-three patients underwent temporary SNS testing with 73.5% positive outcome, of which 52 patients had permanent implant insertion. There were four failures of SNS (7%) following implantation despite successful temporary testing, seven infection, one lead migration and three post-operative pain/numbness. One patient subsequently developed colorectal cancer requiring SNS removal. A higher frequency of episodes of incontinence was associated with positive SNS outcome (p = 0.007). There was no significant association between age, sex, type of faecal incontinence, previous anorectal/pelvic surgery, colonoscopic or USS findings and the likelihood of successful SNS. Of the 52 patients with SNS implants, 27 patients were seen only once for follow-up; the remaining 25 patients were seen more than once - five of these were part of our initial cases of routine 6- and 12-monthly follow-up, 6 patients were seen for adjustment of voltages, whereas the remaining 14 patients were seen for complications of the implants. If the initial five patients were excluded, only 38% of patients would have been seen more frequently on an as-required basis.Conclusion: SNS is a safe and effective option in the management of faecal incontinence. Of the initial work-up, endoscopy and examination-under-anaesthesia (EUA) or proctogram are essential and more likely to influence the likelihood of suitability of SNS testing. A patient-led drop-in approach to follow-up is feasible to allow patients to be seen on an as-required basis. [ABSTRACT FROM AUTHOR]

Background Urgency urinary incontinence (UUI) is a chronic condition for which sacral neuromodulation (SNM) (InterStim/Medtronic) and onabotulinumtoxinA (BTX) (BotoxA/Allergan) are utilized. These therapies have not been compared over extended time. Objective To compare UUI episodes (UUIE) over 24 mo following SNM or BTX. Design, setting, and participants Multicenter, open-label, randomized, extension trial (February 2012–July 2016) at nine US medical centers involving 386 women with ≥6 UUIE over 3 d inadequately managed by medications. Participants were clinical responders to treatment: ≥50% reduction in UUIEs after SNM placement or 1 mo post BTX. Intervention SNM ( n = 194) versus 200 U BTX ( n = 192). SNM reprogrammings occurred throughout the 24 mo. After 6 mo, two additional BTX injections were allowed. Outcome measurements and statistical analysis Primary outcome: change in mean daily UUIE over 24 mo. Secondary outcomes: no UUIE, ≥75% and ≥50% UUIE reduction; Overactive Bladder Questionnaire Short Form; Urinary Distress Inventory short form; Incontinence Impact Questionnaire; Patient Global Impression of Improvement; Overactive Bladder Satisfaction of Treatment Questionnaire; and adverse events (AEs). Primary analysis used a linear mixed model. Results and limitations Outcome data were available for 260/298 (87%) clinical responders. No difference in decreased mean UUIE was found over 24 mo (−3.88 vs −3.50 episodes/d,95% confidence interval [CI] = −0.14–0.89; p = 0.15), with no differences in UUI resolution, ≥75% or ≥50% UUIE reduction. BTX group maintained higher satisfaction (mean difference = −9.14, 95% CI = −14.38–−3.90; p < 0.001), treatment endorsement (mean difference = −12.16, 95% CI = −17.7–−6.63; p < 0.001) through 24 mo. Other secondary measures did not differ. Recurrent urinary tract infections (UTIs) were higher after BTX (24% vs 10%; p < 0.01), 6% required intermittent catheterization post second injection. SNM revision and removals occurred in 3% and 9% patients, respectively. Conclusions Both treatments offered sustainable UUI improvement, and higher BTX dosing had low clean intermittent catheterization rates, but with UTI risk. SNM revision/removal rates were low due to standardized lead placement with strict treatment response definitions. Patient summary We compared a large group of US women with severe urgency urinary incontinence (UUI) who received sacral neuromodulation (InterStim) or onabotulinumtoxinA (Botox A) therapy during a 2-yr period. We found that both therapies had similar success in reducing UUI symptoms, and adverse events were low. However, women in the BotoxA group had higher satisfaction and endorsement with their treatment, but with a higher chance of a urinary tract infection. We conclude that both therapies offer sustained reduction in daily incontinence over 2 yr. [ABSTRACT FROM AUTHOR]

Context Neuromodulation is considered in patients with non-neurogenic lower urinary tract dysfunction (LUTD) not responsive to conservative treatment. Objective To systematically review the available studies on efficacy and safety of sacral neuromodulation (SNM) and percutaneous tibial nerve stimulation (PTNS) in non-neurogenic LUTDs not responsive to conservative treatments. Evidence acquisition A literature research was conducted in PubMed/Medline and Scopus, restricted to articles in English, published between January 1998 and June 2017, with at least 20 patients and 6 mo of follow-up. Evidence synthesis Twenty-one reports were identified. Concerning SNM, the improvement of ≥50% in leakage episodes ranged widely between 29% and 76%. Overall dry rate ranged between 43% and 56%. Overall success/improvement rate in PTNS varied between 54% and 59%. Symptom improvement or efficacy in interstitial cystitis/bladder pain syndrome patients appeared to be lower compared with other indications in both techniques. Safety data showed fewer side effects in patients submitted to PTNS. Conclusions Neuromodulation gives good results and is a safe therapy for patients with overactive bladder or chronic nonobstructive urinary retention with long-lasting efficacy. Moreover, PTNS has been shown to have good success rates and fewer side effects compared with SNM. These data have to be confirmed with long-term follow-up. Patient summary Sacral neuromodulation can improve low urinary tract symptoms in selected patients; it appears to be a safe therapy for nonresponders to standard medical therapies. Percutaneous tibial nerve stimulation (PTNS) is a less invasive technique that gives good results in short time with fewer side effects. However, we must consider that PTNS has not been tested in the long term and results are lower if compared with SNM. [ABSTRACT FROM AUTHOR]

Posterior percutaneous fixation (PPF) can be challenging, particularly in patients with advanced deformity, osteoporosis or prior surgeries. Sacrum S1 pedicle screws breach or misplacement can be related to the anatomic variability of the entry points and the lack of corresponding reliable radiographic landmarks. A reliable intraoperative radiographic description of the S1 pedicle entry point is, therefore, necessary for a safe and reproducible PPF. This study highlights a reproducible anatomical sacral landmark ("V" sign) for the safe localization of the S1 pedicle entry point under fluoroscopy. An anatomic cadaveric study and a retrospective review of patients who had S1 screws placed percutaneously using intraoperative radiographic "V" landmark. Human cadavers (N=14) were dissected for the anatomic description of the "V" landmark. The CT scans of 135 consecutive adult patients were evaluated for the accuracy of S1 pedicle screws percutaneously placed under fluoroscopy and "V" sign guidance. Mean distance between the bottom point of the "V" landmark and the anatomic entry point to the S1 pedicle was measured on all cadavers. Accuracy of percutaneously placed S1 screws using the "V" sign in patients who underwent PPF. Human cadavers were dissected for the anatomic description of the "V" landmark, and its relationship with the anatomic entry point of the S1 pedicle. The spatial "V" landmark was defined medially by the lateral border of the superior facet of S1 and laterally by the posterior projection of the sacral ala. The mean distance between the bottom point of the "V" landmark and the anatomic entry point to the S1 pedicle was measured on all cadavers. Subsequently, a review of CT scans of patients who underwent minimally invasive antepsoas surgery (MIS-ATP) and PPF using the "V" sign as a landmark for S1 pedicle screw placement. Postoperative CT scan S1 screws breaches were collected and graded. In 14 cadavers, the average distance between the bottom point of the "V" landmark and the anatomical entry of the S1 pedicles was 12.0 mm on the left and 11.3 mm on the right. In the medial-lateral axis, all the entry points were within a zone defined +/- 2 mm from the vertical line dropped from the base of the "V". There were no significant differences in this measurement with respect to laterality and sex. Additionally, a retrospective review of 135 patients who underwent percutaneous S1 pedicle screw placement using the "V" landmark showed 8.5% breaches. These were graded as B (5.2%), C (2.2%), D (0.7%), and E (0.4%). Identifying the anatomical entry point to the S1 pedicles under radiographic imaging is crucial for safe MIS surgery. The "V" sign serves as a reliable anatomic and radiographic landmark, situated 12 mm proximal to and on the same vertical line of the anatomical entry of S1 pedicles. This landmark helps the MIS surgeons overcome the radiographic ambiguity of the sacral anatomy, and ultimately mitigates improper S1 pedicle screws placement. S1 Pedicle screws (Approved for this indication) [ABSTRACT FROM AUTHOR]

Objective: To evaluate radiofrequency-induced temperature rises associated with performing lumbar and pelvic magnetic resonance imaging (MRI) studies with an implanted sacral neuromodulation device using a phantom model.Materials and Methods: An accepted phantom model of radiofrequency-induced heating in human tissue was used to measure the temperature rise in the stimulator lead electrodes and impulse generator under the conditions used during routine clinical lumbar and pelvic MRIs in a 1.5Tesla MRI scanner. Testing configurations included an intact device (tined lead connected to generator), an intact lead, and a lead fragment (model of lead fracture). Variations in the position of the phantom relative to the scanner were also tested.Results: During testing with the intact device or the lead fragment no significant heating was detected. In contrast, the isolated intact lead model showed heating up to 5°C.Conclusion: These tests provide preliminary evidence that the risk of heating is low for clinical lumbar and pelvic MRI at 1.5-Tesla with an intact sacral neuromodulation device system and with a fractured lead. However, there is a significant temperature change in the intact lead model. [ABSTRACT FROM AUTHOR]

Introduction The aim of this work is to point out the intraspinal extradural anatomical variations of nerve roots and their possible participation in radiculopathy. Methods The anatomical study was performed in 33 cadavers at a mean age of 46.5 and up to 24 h from death. All extradural anastomoses between nerve roots were excised and examined histologically for the presence or absence of nervous tissue. The type of the plexus was defined by subtracting from the root C2. Results Findings with the normotype of plexus formation prevailed in 24 cases (72.7%). Variations in its formation were observed in 9 cases (27.3%). The prefixed type in 6 cases (18.2%), post-fixed type in 3 cases (9.1%). We did not observe the formation of the isolated prefixed or post-fixed types in the brachial or lumbosacral plexuses. Extradural anatomical variations occurred in 20 cases (60.6%). They were more frequent on the left, in 10 cases (30.3%), bilateral in 3 cases (9.1%). In 8 instances (24.2%), the atypical spacing, including four in the lumbosacral region, was observed. Variations occurred more frequently in variations of formation of the plexus. Conclusions This study allowed us to identify and describe unpublished intraspinal extradural anatomical variations of nerve roots and their interrelationships throughout the spinal canal with their potential influence on the clinical picture. Anatomical preparations revealed a higher incidence of intraspinal extradural variations, mainly between sacral roots. The reliance of their incidence of the type of plexus was observed. [ABSTRACT FROM AUTHOR]

Purpose: Treatment of spine and sacral chordoma generally involves surgical resection, usually in conjunction with radiation therapy. In certain circumstances where resection may result in significant neurologic or organ dysfunction, patients can be treated definitively with radiation therapy alone. Herein, we report the outcome and the assessment of tumor response to definitive radiation therapy.Methods and Materials: A retrospective analysis was performed on 40 patients with unresected chordoma treated with photon/proton radiation therapy. Nineteen patients had complete sets of imaging scans. The soft tissue and bone compartments of the tumor were defined separately. Tumor response was evaluated by the modified Response Evaluation Criteria in Solid Tumors (RECIST) and volumetric analysis.Results: With a median follow-up time of 50.3 months, the rates of 5-year local control, overall survival, disease-specific survival, and distant failure were 85.4%, 81.9%, 89.4%, and 20.2%, respectively. Eighty-four computed tomographic and magnetic resonance imaging scans were reviewed. Among the 19 patients, only 4 local failures occurred, and the median tumor dose was 77.4 GyRBE. Analysis at a median follow-up time of 18 months showed significant volumetric reduction of the total target volume (TTV) and the soft tissue target volume (STTV) within the first 24 months after treatment initiation, followed by further gradual reduction throughout the rest of the follow-up period. The median maximum percentage volumetric regressions of TTV and STTV were 43.2% and 70.4%, respectively. There was only a small reduction in bone target volume over time. In comparison with the modified RECIST, volumetric analysis was more reliable, more reproducible, and could help in measuring minimal changes in the tumor volume.Conclusion: These results continue to support the use of high-dose definitive radiation therapy for selected patients with unresected spine and sacral chordomas. Assessment of tumor response to radiation therapy by volumetric analysis is superior to modified RECIST in chordoma patients. Evaluating the soft tissue target volume is an excellent indicator of tumor response. [ABSTRACT FROM AUTHOR]

The crossed spinocerebellar tracts originate from neurons in the basolateral part of lamina V, the sacral nuclei of Stilling and the ventrolateral part of the ventral horn of the L6 to caudal segments. The present study examined their projection areas in the cerebellar cortex by using anterograde labeling of mossy fiber terminals with biotinylated dextran in the rat. Labeled terminals were distributed bilaterally in lobules I–V of the anterior lobe. They were most abundant in the apical parts of the lateral vermis and the intermediate region of lobules Ib and IIa, and the rostral side of lobule IIb. The number of labeled terminals in lobules Ib-IIb accounted for 56% and 81%, respectively, of the total 9783 and 7045 labeled terminals. The number of labeled terminals decreased in lobules III to V. In the posterior lobe labeled terminals were distributed exclusively to lobules VIIIa and VIIIb and copula pyramidis. The present study demonstrates that spinocerebellar neurons of the sacral-caudal segments project primarily to the lateral part of lobules I and II, and less densely to lobules III–V and VIII, and copula pyramidis. The projection pattern was essentially similar to that observed in the cat. [ABSTRACT FROM AUTHOR]

Sacral neuromodulation (SNM) is a minimally invasive, restorative treatment to improve voiding and elimination functions. We give a historical perspective of SNM and explore the evidence for the use of this therapy for Food and Drug Administration-approved pathologies as well as disease processes that are being treated internationally. Ensuring optimal lead placement increases the potential of a comfortable, durable, and efficacious response. The future of SNM aims to maximize its potential benefit, refine its use, and minimize its risks and cost. Evolution of the therapy includes better device options, better software for patient and clinician use, more programming capabilities, and new nerve targets. [ABSTRACT FROM AUTHOR]

Background Neurogenic bladder refers to dysfunction of the urinary bladder secondary to diseases of the nervous system that result in problems with urine storage, micturition, or both. The most common causes are multiple sclerosis and spinal cord injury. Patients commonly present with recurrent UTIs, obstructive uropathies, and urinary retention. Without proper treatment, neurogenic bladder may result in nephropathy and renal failure, both of which have a significant negative impact on the health and life expectancy of patients. Restoration of lost neural function using artificial stimulators is a feasible therapeutic strategy. This article reviews the pathophysiology of neurogenic bladder and the 2 most commonly employed sacral nerve stimulation methods—the Brindley procedure and sacral neuromodulation. [ABSTRACT FROM AUTHOR]

Background Context: Accurate determination of the extent of trunk imbalance in the coronal plane plays a key role in an evaluation of patients with trunk imbalance, such as patients with adolescent idiopathic scoliosis. An established, widely used practice in evaluating trunk imbalance is to drop a plumb line from the C7 vertebra to a key reference axis, the central sacral vertical line (CSVL) in full-spine standing anterioposterior radiographs, and measuring the distance between them, the C7-CSVL. However, measuring the CSVL is subject to intraobserver differences, is error-prone, and is of poor reliability. Therefore, the development of a different way to measure trunk imbalance is needed.Purpose: This study aimed to describe a new method to measure coronal trunk imbalance, the axis-line-angle technique (ALAT), which measures the angle at the intersection between the C7 plumb line and an axis line drawn from the vertebral centroid of the C7 to the middle of the superior border of the symphysis pubis, and to compare the reliability of the ALAT with that of the C7-CSVL.Study Design/setting: A prospective study at a university hospital was used.Patient Sample: The patient sample consisted of sixty-nine consecutively enrolled men and women patients, aged 10-18 years, who had trunk imbalance defined as C7-CSVL longer than 20 mm on computed full-spine standing anterioposterior radiographs.Outcome Measures: Data were analyzed to determine the correlation between C7-CSVL and ALAT measurements and to determine intraobserver and interobserver reliabilities.Methods: Using a picture archiving and communication system, three radiologists independently evaluated trunk imbalance on the 69 computed radiographs by measuring the C7-CSVL and by measuring the angle determined by the ALAT. Data were analyzed to determine the correlations between the two measures of trunk imbalance, and to determine intraobserver and interobserver reliabilities of each of them.Results: Overall results from the measurements by the C7-CSVL and the ALAT were significantly moderately correlated. Intraobserver assessments by measuring the C7-CSVL and by doing the ALAT failed to find any significant differences between the findings from the first and second assessments by the same radiologist. Interobserver assessments significantly differed between radiologists 1 and 2 for the first assessment measuring the C7-CSVL, and between radiologists 2 and 3 for the second assessment measuring the C7-CSVL. Interobserver assessments by doing the ALAT failed to find any significant differences among the three radiologists for either of the two assessments.Conclusions: Our results indicated that using the ALAT, which is simple and convenient, is of great value in measuring trunk imbalance. For measuring trunk imbalance, the ALAT has essential advantages compared with measuring the C7-CSVL. We encourage spine surgeons to consider using the ALAT in evaluating trunk imbalance. [ABSTRACT FROM AUTHOR]

Introduction: Fecal incontinence is a debilitating condition affecting primarily the elderly. Many patients suffer in silence resulting in both underdiagnosis and undertreatment often culminating in an overall poor quality of life.Methods: We sought to review the etiology, diagnosis, and treatment of fecal incontinence based on current literature. Additionally, newer treatment methods such as Solesta will be evaluated.Results: There are many diagnostic modalities available to assess the degree and severity of the patient's incontinence; however, a thorough history and physical exam is critical. Initial attempts at treatment focus on medical management primarily through stool texture modification with the aid of bulking agents. Failure of medical therapy is often followed by a graded increase in the complexity and invasiveness of the available treatment options. The selection of the most appropriate surgical option, such as overlapping sphincteroplasty and neuromodulation, is multifactorial involving both surgeon and patient-related factors. Neuromodulation has received increased attention in the last decade due to its documented therapeutic success, and newer office-based procedures, such as the Solesta injection, are showing promising results in properly selected patients. Finally, diversion remains an option for select patients who have failed all other therapies.Conclusion: The etiology of fecal incontinence is multifactorial, involving a complex interplay between stool consistency and anatomic integrity. The diagnosis and treatment of fecal incontinence continue to evolve and are showing promising results. [ABSTRACT FROM AUTHOR]

• Two novel navigation systems to guide electrode placements in sacral nerve stimulation procedures. • Real-time needle guidance with optical tracking system or smartphone-based augmented reality. • Experimental results on a realistic phantom show reduced insertion time and number of punctures, suggesting improved surgical outcome when using our navigation systems. • The clinical method simulation could be an alternative training solution for sacral nerve stimulation. Sacral nerve stimulation (SNS) is a minimally invasive procedure where an electrode lead is implanted through the sacral foramina to stimulate the nerve modulating colonic and urinary functions. One of the most crucial steps in SNS procedures is the placement of the tined lead close to the sacral nerve. However, needle insertion is very challenging for surgeons. Several x-ray projections are required to interpret the needle position correctly. In many cases, multiple punctures are needed, causing an increase in surgical time and patient's discomfort and pain. In this work we propose and evaluate two different navigation systems to guide electrode placement in SNS surgeries designed to reduce surgical time, minimize patient discomfort and improve surgical outcomes. We developed, for the first alternative, an open-source navigation software to guide electrode placement by real-time needle tracking with an optical tracking system (OTS). In the second method, we present a smartphone-based AR application that displays virtual guidance elements directly on the affected area, using a 3D printed reference marker placed on the patient. This guidance facilitates needle insertion with a predefined trajectory. Both techniques were evaluated to determine which one obtained better results than the current surgical procedure. To compare the proposals with the clinical method, we developed an x-ray software tool that calculates a digitally reconstructed radiograph, simulating the fluoroscopy acquisitions during the procedure. Twelve physicians (inexperienced and experienced users) performed needle insertions through several specific targets to evaluate the alternative SNS guidance methods on a realistic patient-based phantom. With each navigation solution, we observed that users took less average time to complete each insertion (36.83 s and 44.43 s for the OTS and AR methods, respectively) and needed fewer average punctures to reach the target (1.23 and 1.96 for the OTS and AR methods respectively) than following the standard clinical method (189.28 s and 3.65 punctures). To conclude, we have shown two navigation alternatives that could improve surgical outcome by significantly reducing needle insertions, surgical time and patient's pain in SNS procedures. We believe that these solutions are feasible to train surgeons and even replace current SNS clinical procedures. [ABSTRACT FROM AUTHOR]

Sacral nerve stimulation (SNS) was originally developed in the field of urinary incontinence. Without adaptation, it was subsequently applied to treat faecal incontinence. SNS has now become a first line therapy for this socially disabling condition, however the mechanism of action is unknown. This review examines the evidence for stimulation parameters currently used for SNS in humans and considers the potential electrophysiological effects of changing these parameters. However, without a proper understanding of the physiology of SNS, changing stimulation parameters remains empirical. [ABSTRACT FROM AUTHOR]